Turning an eye on the profession, separating fact from fiction on both sides of the counter

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You may consider yourself a critical thinker and scientific skeptic, but do you have any blind spots? I’ve had a skeptical perspective for a long time (my teenage cynicism wasn’t just a phase) but the framework for my thinking has developed over years. Professionally, the blind spot that the pharmacy profession has towards supplements and alternatives to medicine was only clear after I spent some time working in a pharmacy with thriving homeopathy sales. In looking for some credible evidence to guide my recommendations, I discovered there was quite literally *nothing* to homeopathy. Once I discovered blogs like Respectful Insolence, the critical thinking process, and scientific skepticism, took off from there.

While my critical thinking about medicine is now pretty sharp, I’m discovering that I’ve had blinders one when it comes to a lot of the science of health and fitness. For context, I am regular runner and swimmer and work out several times per week. For a time, I considered myself to be a triathlete, and even managed to complete an Ironman triathlon. Now I exercise because I like it. (Plus I have an unreasonable fear of cardiovascular disease.) But my exercise practices developed through a combination of expert opinion, personal experimentation and anecdotes from others. Judging by conversations with others, I suspect this isn’t uncommon. So I run with Gatorade, stretch after my workouts, and sometimes have a protein shake after my weekly long run. Science-based? I rarely paused to ask. Here I sound like a CAM advocate: It worked for me.
The superstitions of top athletes are well known, but what’s less well known is the extent to which the conventional knowledge about diet, fitness, and nutrition also lack good scientific evidence. I have blogged here about the occasional topics related to health and fitness, but blog posts don’t tend to offer the general overview and analytic framework that can guide the new reader. I also recognize that blogs are not a primary source of information to many people, so any credible sources in other formats that I can refer to are always welcomed.

I’ve found two excellent references to recommend. The first is Timothy Caulfield’s “The Cure For Everything”. Caulfield is a professor in the Faculty of Law and School of Public Health at the University of Alberta. His book is an accessible, engaging read into the world of health, fitness, and alternative medicine. The book’s subtitle is “Untangling Twisted Messages about Health, Fitness and Happiness” and that’s exactly what Caulfield does – with a personal perspective. While an academic by training, Caulfield doesn’t just regurgitate the evidence. In fact, he really tries to understand different perspectives, and does this by immersing himself fully into his topics. Caulfield is a strong advocate for the use of science to guide decision-making:

At a time when scientific information has never been more important, it is being subjected to an unprecedented number of perverting influences. Not that this should come as a surprise. As science becomes more central to our lives, the stakes grow higher the incentives to twist the scientific message multiply.

Tim also zeroes in on an important point in how we teach people to make better scientific decisions:

May scientists believe that if people just knew more about science or understood the facts, they would be more rational about their health decisions. This view, which has been called the deficit model, is faulty. Research has shown that learning bout science can have a dramatic impact on a person’s views about health issues – as I optimistically and perhaps naively hope this book will- but that this is not the norm. Supplying individuals with facts rarely alters beliefs. People see, select and interpret information about health (and many other topics) through individual and largely self-constructed lenses of preconceived beliefs, values, and fears.

Tim’s approach to this is to treat each topic with a mix of personal anecdotes and contrast it with what the scientific evidence actually says. Like the SBM blog, the book doesn’t just focus on CAM – his exploration includes the spin of both the pharmaceutical industry and the direct-to-consumer genetic testing industry, show that the twisting of science for marketing purposes is hardly the exclusive domain of the CAM advocate.
Caulfield’s chapter on fitness is where I personally learned the most. He contrasts the marketing of fitness (all about sex appeal and 6-pack abs) with the unequivocal health benefits conferred – despite the fact that dramatically changing our appearance due to exercise alone is near-impossible. That’s because exercise is spectacularly bad at producing weight loss. Caulfield attributes much of the inaccurate messaging about diet and exercise to the food industry, which tends to portray inactivity as a driver of obesity, rather than suggesting the avoidance of calorie-dense, nutritionally-poor foods.

While it’s an evidence-based book, Caulfield’s personal experience make the book read more of a personal odyssey. You’re never left wondering what the science says, but it’s distilled with his own particular perspective. Caulfield gleefully debunks is the idea that stretching is both necessary and good. (Raise your hand if you spent hours in gym class doing static stretching.) The evidence actually shows that there’s little data to support routine stretching for preventing injuries. And stretching may impair, rather than benefit, a range of athletic activities.

Caulfield argues that the importance of strength (resistance) training for people of all ages and fitness levels has been under-emphasized, and uses this to recommend approaches to maximize your gains. He drives home the evidence demonstrating a clear dose-response to exercise – so intensity is key. Public health messages that advocate “moderate” exercise (which make sense when targeting a largely sedentary population) have obscured the reality that it is the intensity of exercise that drives health gains. For this reason, he is critical of yoga, which is far less effective than most other forms of exercise at building strength or cardiovascular benefits. Again, it’s the marketing of yoga (a multi-billion dollar industry now) that creates the perception of the health value of yoga, which is largely unsubstantiated.
The section on diet starts with some simple questions: “What, when and how much should I eat?” that he poses to a panel of diet experts he assembles – and then follows their science-based advice for three months. Without spoiling the surprise, Caulfield describes the impact of his own experiment while weaving in what the evidence says – and has some remarkable results along the way – all without miracle pills, supplements, and gimmicks.
The chapter on the alternative health industry will be the most familiar to readers of this blog. Caulfield is a strong science-based medicine advocate and he understands and explains how CAM advocates spin evidence and market themselves in ways to adopt the veneer of science, without the substance. As part of his research, he even visits a naturopath, describing the visit as “the most pleasant clinical experience I have ever had.” The naturopath’s prescription to prevent motion sickness? Deep breathing, supplements, acupuncture, and homeopathy. Caulfield actually has his session with the acupuncturist, and takes his homeopathic nostrums as directed on an Alaskan cruise, with expected results. He goes on to a deep dive into naturopathy, and his evisceration of the vitalistic premise and mystical evidence base for naturopathy would make Kimball Atwood proud. He notes that naturopaths can offer reasonable and scientifically sound advice – but argues that this is only when they happen to align with naturopathic philosophies – not because they have been evaluated by naturopaths from a scientific perspective. Caulfield emphasizes that naturopaths crave mainstream legitimacy, yet refuse to renounce the magical (and debunked) framework that guides naturopathic practices:

If people want to go to alternative practitioners because they enjoy the personal attention (and I sure did), because they appreciate the holistic approach to health, because they are attracted to the underlying philosophy and are comfortable with the lack of evidence, then I say go for it. But if the field claims to be scientifically informed, as is the case with modern naturopathic practice, then it must follow the principles of science, And practitioners should not deceive patients about what the evidence says.

Homeopathy is an easy target, for sure. It is universally accepted by those within the scientific community that it’s a crock. But that is why it serves as such a damning example of the twisting power of an overriding ideological framework. If naturopathy was really evidence based, would naturopaths provide homeopathy as a primary treatment? Is the use of homeopathy supported by “voluminous research” as claimed by the head of the British Columbia naturopaths’ association? Or do naturopaths hold on to a belief in this therapy because it is part of the naturopathic tradition and accords closely with the foundational (and unscientific) principles of the field? The answers to these questions are patently obvious.

Because of Caulfield’s work in area, he’s been widely quoted in the past weeks as the Province of Alberta has announced plans to register and regulate naturopathy. So much for evidence-based health policy. For anyone that needs an introduction to science-based medicine, and the importance of making health decisions based on good scientific evidence, Caulfield’s book is an excellent entry point.

Which comes first, cardio or weights?The second book which I’m just as excited about is Alex Hutchinson’s “Which comes first, cardio or weights? I became aware of Alex’s work through regular columns in the Globe and Mail which stood out from the usually health and fitness tripe in that they were strongly evidence-based. A journalist with a PhD in physics, Alex is excellent writer plus an accomplished distance runner. (A combination I aspire to, but fail on both counts). Hutchinson brings a mix of pragmatism and science to his blog at Runner’s World, which is also reflected in his new book, which answers dozens of pertinent health and fitness questions, such as:

Are elliptical trainers useful?

Is “barefoot running” all it’s touted to be?

Is there really a “fat burning zone” for my heart, and should I target it?

What should I eat or drink before, during, and after workouts?

Does listening to music help or hurt my workout?

What athletic shoes do I really need?

How does exercise affect my immunity?

Will running ruin my knees?

Can you change your running style? Should you?

Should I stretch?

Do compression garments help performance or recovery?

Is it lactic acid buildup that’s causing muscle fatigue?

What is an exercise “stitch” and how do I prevent them?

Are those maximum heart rate charts in the gym accurate?

Well referenced and grounded in the evidence, I have little to critique about the book. I don’t want to spoil the read for you – I learned a tremendous amount about my own blind spots of exercise, which is going to help not only my own fitness habits, but also the advice I offer to others. Compared to Caulfield’s book, this is a much “deeper dive” into the specifics of exercise, but it’s an excellent read for anyone interested in maximizing the gains from exercise. Both books are exceptional in the way they cut through the noise we’re exposed to everyday when it comes to diet, health and fitness advice.

Great science-based references that are accessible to a general audience are hard to come by. I am happy to recommend “The Cure for Everything” and “Which comes first, cardio or weights?” unequivocally.

I will definitely look up the second one. I know just enough exercise science to know that the majority of what’s in runner’s magazines is junk but not enough to know for sure what is the good stuff that I should pay attention to.